Provider Demographics
NPI:1225214505
Name:FOX, KELLY JEAN (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:FOX
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:COPPER CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:75077-4815
Mailing Address - Country:US
Mailing Address - Phone:817-685-2598
Mailing Address - Fax:
Practice Address - Street 1:1212 N HIGHWAY 377
Practice Address - Street 2:#119
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-6916
Practice Address - Country:US
Practice Address - Phone:682-831-1591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX582397363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily